DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They
are intended to serve as a general statement regarding appropriate patient care practices based upon the available medical
literature and clinical expertise at the time of development. They should not be considered to be accepted protocol or policy, nor are
intended to replace clinical judgment or dictate care of individual patients.
• Class I: Prospective randomized controlled trial.
• Class II: Prospective clinical study or retrospective analysis of reliable data. Includes observational, cohort, prevalence, or case
• Class III: Retrospective study. Includes database or registry reviews, large series of case reports, expert opinion.
• Technology assessment: A technology study which does not lend itself to classification in the above-mentioned format.
Devices are evaluated in terms of their accuracy, reliability, therapeutic potential, or cost effectiveness.
LEVEL OF RECOMMENDATION DEFINITIONS
• Level 1: Convincingly justifiable based on available scientific information alone. Usually based on Class I data or strong Class II
evidence if randomized testing is inappropriate. Conversely, low quality or contradictory Class I data may be insufficient to
support a Level I recommendation.
• Level 2: Reasonably justifiable based on available scientific evidence and strongly supported by expert opinion. Usually
supported by Class II data or a preponderance of Class III evidence.
• Level 3: Supported by available data, but scientific evidence is lacking. Generally supported by Class III data. Useful for
educational purposes and in guiding future clinical research.
1 Approved 05/16/2005
CHEST TUBE MANAGEMENT
Tube thoracostomy, or chest tube (CT) placement, is often indicated for the treatment of pneumothorax,
hemothorax, or pleural effusion following traumatic injury or thoracic surgery. Subsequent management of
the CT must be individualized to the patient, taking into consideration the reason for CT placement,
whether or not the patient has had pulmonary resection, and whether the patient is mechanically
ventilated. Premature CT removal, as well as unnecessary delays in CT removal, leads to increased
hospital stays and costs.
Tube thoracostomy, or chest tube (CT) placement, is often indicated for the treatment of pneumothorax
(PTX) and/or hemothorax (HTX). Although there is generally agreement among surgeons on the
indications and technique for CT insertion, there is little consensus on the subsequent management of
these tubes once placed. Management practices are often based on institution and physician-specific
training and preferences developed from anecdotal experience. The ideal CT management algorithm has
yet to be determined. Specifically, wide variation in management practices exists in regards to the timing
• Level 1
CT drainage should be ≤ 2ml/kg/day or ≤ 200 ml/day (whichever is less) before removal.
• Level 2
CTs can be removed equally safely at end-inspiration or end-expiration.
CTs may be safely removed on suction.
A brief trial of waterseal prior to CT removal may allow occult air leaks to become
clinically apparent and reduce the need for CT reinsertion due to recurrent
pneumothorax. Such trials, however, will generally increase hospital length of stay and
the number of chest radiographs (CXRs) obtained.
After pulmonary resection, small air leaks will resolve significantly more quickly if the CT
is placed to water seal
• Level 3
In non-mechanically ventilated patients, a routine CXR following removal of a CT is
generally not indicated. The decision to obtain a CXR should be based on the individual
clinical situation and the patient’s signs and symptoms.
In mechanically ventilated patients, a CXR obtained between one and three hours after
removal of a CT is sufficient to identify a recurrent pneumothorax.
A daily CXR is not indicated to monitor CTs in the intensive care unit. Routine
monitoring and patient care will identify the need for CXR based on clinical necessity.
2 Approved 5/16/2005
and parameters under which CTs should be removed, the best method of removal, and the need for chest
X-rays to monitor patients pre- and post-CT removal.
What volume of CT drainage is appropriate to consider removal of the tube?
In 2002, Younes performed a prospective randomized study to evaluate the timing of CT removal in
regards to the daily CT drainage volume (1). Specifically, the study compared removal when drainage
was ≤ 100 ml/day, ≤ 150-ml/day or ≤ 200 ml/day. Fluid reaccumulation and the need for thoracentesis
were evaluated. No major differences were noted between the groups, concluding that increasing the
threshold of daily drainage to 200 ml before removing the CT could lead to quicker removal of the CT,
reducing hospitalization time and overall cost. Davis defined drainage resolution as <2ml/kg (2). Although
the study did not specifically evaluate patients for the recurrence of pleural fluid, this parameter was not
reported to adversely influence study outcomes. A level of 2ml/kg is equivalent to 200ml in a 100 kg
patient; it is therefore possible in this study that 24-hour drainage totals were higher than 200ml when the
CT was removed, if the patient weighed more than 100 kg.
Should CTs be removed at end-inspiration or end-expiration?
Bell designed a prospective, randomized study to evaluate whether a recurrent pneumothorax (PTX) was
more likely with CT removal at end-inspiration or end-expiration (3). Of 102 CTs in 69 blunt and
penetrating trauma patients, 50 were assigned to end-expiration removal versus 52 assigned to end-
inspiration removal. The results showed an 8% rate of recurrent PTX in the end-inspiration group and 6%
rate in the end-expiration group (p=1.0). No other factors were identified that predisposed to recurrent
PTX. The study concluded that the risk of recurrent PTX was similar between both groups and that either
method of CT removal was safe.
Should CTs be removed on water seal or on suction?
In 1994, Davis published a randomized prospective study designed to determine the differences between
removing CTs on suction versus removal on water seal (2). Eighty trauma patients were included,
randomizing 40 patients to each arm. Patients on mechanical ventilation, post-thoracotomy patients and
patients with multiple CTs were excluded. Patients were randomized to their respective study arms when
the CT showed no evidence of an air leak and drainage was < 2 ml/kg over 24 hours. Prior to CT
removal, CTs in the water seal group were taken off suction and chest X rays (CXRs) were obtained at six
and 24 hours to evaluate for recurrent PTX. If a recurrent PTX was seen, the patient was placed back on
suction for 24 hours and the process repeated. If no recurrent PTX was appreciated, the CT was
removed. In the suction group, CTs remained on suction for 24 hours after resolution of the air leak. No
additional CXRs were obtained before removal. In both groups following CT removal, a CXR was
obtained immediately and at 8-12 hours post-pull. Only two recurrent PTX were seen in the suction group
and one in the water seal group; only one patient in each group required replacement of tube (1/40 or
2.5%). Patients in the water seal group had CTs in place on average 20.3 hours longer than the suction
group, and they required more CXRs to monitor their care. This study concluded that CT removal on
suction was safe, and protocols using water seal before removal led to a longer hospital length of stay
and an increased number of CXRs.
Martino also published a prospective, randomized study to determine whether CT removal on suction
allowed for shorter CT duration than removal on water seal (4). Two hundred and five trauma patients
were included, with 93 patients (45%) in the water seal group and 112 (55%) in suction group. Patients on
mechanical ventilation for >24 were excluded. Patients were randomized to their respective study arms
when CT drainage was <150 cc/24 hrs and there was no significant PTX or air leak. Patients in the water
seal group had their tubes removed from suction and a CXR obtained 6-8 hours later. Four patients in the
water seal group developed a PTX and the CTs were placed back on suction and the process repeated.
Patients in the suction group had their CT disconnected from suction, and the CT was pulled immediately.
Following CT removal, a recurrent PTX was seen in 13 patients in the water seal group, only one of which
required replacement of the tube. In the suction group, 9 patients had recurrent PTX and 7 required
replacement of a tube. This study concluded that the water seal group was more likely to have a recurrent
PTX after CT removal, but was less likely to need CT replacement. Additionally, the average number of
3 Approved 5/16/2005
CXRs in the water seal group was 6.5 compared to 5.5 in suction group. Initially, there was no significant
difference in CT duration or hospital length of stay (LOS). If CT replacement were required, however,
hospital LOS was twice as long. The study concluded that a short trial of water seal might allow occult air
leaks to become clinically apparent and reduced the need for another CT. Two further studies were
performed regarding the question of CT removal on suction versus water seal, specifically focusing on the
management of patients after pulmonary resection. In 2001, Cerfolio performed a randomized,
prospective trial to evaluate whether CTs should be placed on water seal or suction after pulmonary
surgery to stop air leaks (5). Additionally this study established a classification method to characterize the
air leak. Included were 140 consecutive patients undergoing elective pulmonary resection by a single
surgeon. Excluded were patients undergoing exclusively Video Assisted Thorascopic Surgery (VATS),
lung volume reduction surgery, pneumonectomy, or sleeve resection. On post-operative day (POD) #2,
patients with air leaks were either placed in the pre-randomized suction versus water seal groups. There
were 18 patients in the water seal group and 15 patients in the suction group. In the water seal group, 12
of the 18 patients (67%) had no further leak by POD#3. The remaining six who had a persistent leak had
leaks that were characterized as ≥ 4/7 in size (per the Pleurovac leak meter). In the suction group, only 1
of the 15 had stopped the air leak by POD #3. The remaining 14 patients were then placed to water seal.
Of these 14 patients, 13 had no further air leaks by POD #4. The total number of patients ultimately
placed on water seal was 32 (18 + 14); 25 of these (78%) had air leaks that stopped and all were leaks
that were characterized as ≤ 3/7 on the leak meter. Of these 25, 23 had leaks that stopped within 24
hours after being put on water seal. Out of the 32 pts, seven had developed a PTX on water seal. Six out
of 7 had leaks characterized as ≥ 4/7 on the leak meter. This study came to the conclusion that placing
CTs on water seal seems to be superior to wall suction for stopping air leaks after pulmonary resection.
However, water seal does not stop leaks that are characterized as 4/7 or greater. A PTX may occur on
water seal with leaks this large. In 2002, Marshall also performed a randomized, prospective study to
evaluate suction versus water seal for the management of CTs after pulmonary resection (6). Sixty-eight
consecutive patients undergoing wedge resection, segmentectomy, or lobectomy were randomized to
water seal or suction groups. After surgery, all patients had their CTs placed to -20 cm H2O suction in the
operating room to establish initial expansion of the lung, followed by removal from suction for transport to
the post-anesthesia care unit (PACU). In the PACU, patients were randomized to the water seal or
suction group. If patients in the water seal group had > 25% PTX upon arrival to the PACU, the CT would
be put on -10cm H2O suction until resolution of the PTX; then it was placed back on water seal. The CT
was removed when the air leak resolved and the drainage was < 300 ml/24 hrs. Patients in the suction
group were kept on suction until the air leak resolved, and then placed on water seal. The tube was
removed when the drainage was < 300 ml/24 hrs. Of note, adjustments to the data were made taking into
consideration the length of pulmonary staple lines for comparison. Study results showed that air leaks in
the water seal group lasted a mean of 1.5 days ± 0.3 days. Air leaks in the suction group lasted an
average of 3.3 days ± 0.8 days (p=0.05). CTs in the water seal group were in place an average of 3.3
days ± 0.4 days. CTs in the suction group were in place an average of 5.5 ± 1.0 days (p =0.06). This
study concluded that the duration of air leaks in the water seal group was approximately half of that
observed in the suction group. The study surmised that the leak was kept open by the suction, and when
placed on water seal, the decreased volume of leaking air allowed lung parenchyma to heal more readily.
When should CXRs be obtained after removal of a CT?
In 2000, Pacanowski performed a retrospective review of 105 patients with 113 CTs to see if routine CXR
after CT removal in traumatic hemopneumothorax (HPTX) offered any benefit over clinical evaluation of
respiratory status (7). In this study, CTs were removed after a 24-hour period of water seal and CT output
was < 100ml/24 hrs. Prior to removal, a CXR was performed to confirm resolution of the HPTX. CTs were
then removed at peak inspiration. Follow-up CXRs were obtained on average 8 and 22 hours after
removal. Recurrent HPTX was considered a HPTX seen on post-pull films, but not on prepull film.
Persistent HPTX was defined as a stable HPTX evident on pre-removal and post-removal films. Study
results showed that the average duration of CT placement was 5 days. Twelve patients (11%) had
recurrent PTX and one required replacement of the CT for reaccumulation of a hemothorax. Nine of the
12 recurrent HPTX were evident at time of the first post-removal CXR. All 12 recurrences were evident
within 24 hours post CT removal. Three patients had “symptoms” (dyspnea, shortness of breath, or chest
pain) after removal, but none had a PTX. This study concluded that after completing a trial of water seal,
4 Approved 5/16/2005
clinical assessment of respiratory status was sufficient to identify recurrent HPTX requiring further
intervention. However, being retrospective in nature, the authors advocated obtaining a single upright
CXR 24 hours after CT removal to evaluate for recurrent HPTX. In 2002, Palesty came to a similar
conclusion in a retrospective review that looked at 73 patients (8). Although the timing of post-removal
CXRs varied, all had a CXR performed within 24 hours of removal in addition to the CXR performed prior
to removal. Eight patients had post-removal CXRs that differed from the pre-removal film; of these, only
two patients required replacement of a CT. Although a CXR had been obtained, the decision to replace
the CT was primarily based on clinical findings, however. The study concluded that obtaining a CXR
following CT removal should be based on sound clinical judgment and discrimination of the surgeon.
These results were also in agreement with Pacharn9, who performed a one-year, retrospective review of
pediatric cardiac surgery patients to evaluate the benefit of CXRs following CT removal. The study
concluded that in this population, clinical signs and symptoms identified nearly all patients with significant
PTX, and that CXR should be reserved for select, high-risk groups and those with clinical signs and
McCormick performed a retrospective review evaluating 703 postoperative cardiac patients who
underwent routine CXR after CT removal, and 297 who received no imaging (10). In those who received
a CXR the incidence of intervention was 1.7%. In those who received no CXR, the incidence of
intervention was 0.6% (p=0.25). The CXR prompted intervention in four patients who were asymptomatic.
This raised the possibility that these patients may have done well without intervention, and that CXR may
have had a deleterious effect on patient care. The study concluded that omission of routine CXRs
following CT removal is safe, and that liberal use of clinical indications for imaging should be encouraged.
Pizano prospectively evaluated the timing of post-CT removal patients in mechanically ventilated patients
(11). Seventy-five patients on positive pressure ventilation were evaluated with CXRs obtained at one
hour, 10 hours, and 36 hours post CT removal. Nine of the 75 patients (12%) had a PTX following CT
removal, all of which were seen on the first (one-hour) CXR. Only 2 of the 9 patients required
replacement of the CT. The authors concluded that a CXR obtained within 3 hours after CT removal
effectively identifies a PTX in mechanically ventilated patients.
Should a daily CXR be obtained when a patient has a CT?
Silverstein concluded in a 1993 prospective review of 525 routine morning intensive care unit CXRs that
cardiopulmonary findings were noted on only 89 (12%) (12). Of these, only 3 cases required immediate
action by the physician based solely on the CXR findings. The study also examined the use of CXRs to
monitor medical devices such as CTs. Out of the 120 CTs seen on CXR, only three (2.5%) were in minor
incorrect position (not requiring manipulation) and only 1 (0.8%) was in major incorrect position, requiring
manipulation. His conclusions were that routine daily CXRs were unwarranted, particularly if the goal is to
monitor position of a medical device such as a CT.
5 Approved 5/16/2005
CHEST TUBE MANAGEMENT ALGORITHM
Chest tube present
need for CT
Is CT drainage <
Does CT have
an air leak?
Place CT on water
seal for 24 hrs
Obtain CXR 3 hrs
Place CT on water
seal for 24 hrs
Is there a
Obtain CXR only if
Continue CT on
6 Approved 5/16/2005
1. Younes RN, et al. When to Remove a CT? A Randomized Study with Subsequent Prospective
Consecutive Validation. J Am Coll Surg 2002; 195:658-662.
2. Davis, J et al. Randomized Study of Algorithms for Discontinuing Tube Thoracostomy Drainage. J Am
Coll Surg 1994; 179:553-557.
3. Bell R et al. CT Removal: End-Inspiration or End-Expiration? J Trauma; 2001; 50:674-676.
4. Martino K et al. Prospective Randomized Trial of Thoracostomy Removal Algorithms. J Trauma 1999;
5. Cerfolio RJ et al. Prospective Randomized Trial Compares Suction vs. Water Seal for Air Leaks. Ann
Thoracic Surg 2001; 71:1613-1617.
6. Marshall MB et al. Suction vs. Water Seal After Pulmonary Resection: A Randomized Prospective
Study. Chest 2002: 121:831-835.
7. Pacanowski J et al. Is Routine Roentgenography Needed after Closed Tube Thoracostomy Removal?
J Trauma 2000; 48:684-688.
8. Palesty JA et al. The Efficacy of X-rays after CT Removal. Am J Surg 2000; 179:13-16.
9. Pacharn P et al. Are Chest Radiographs Routinely Necessary Following Thoracostomy Tube
Removal? Pediatric Radiology 202; 32:138-142.
10. McCormick JT et al. The Use of Routine Chest X-Ray Films after CT Removal in Postoperative
Cardiac Patients. Ann Thorac Surg 2002; 74:2161-2164.
11. Pizano LR et al. When Should Chest Radiograph be Obtained after CT Removal in Mechanically
Ventilated Patients? A Prospective Study. J Trauma 2002:53:1073-1077.
12. Silverstein D et al. The Utility of Routine Daily Chest Radiography in the Surgical Intensive Care Unit
J Trauma 1993; 35:643-646.